Work reconfiguring and improving the quality of ambulance services has been underway in the Health Services Executive for years. But official targets involving emergency call-out times are being regularly missed and rural communities continue to receive an inadequate service. A rapid ambulance response can be the difference between life and death. Life-threatening injuries from a crash, a stabbing, or a major medical trauma are obvious examples. But survival rates in respiratory cases are also much better if paramedics arrive before the onset of cardiac arrest.

Yet ambulance crews are being forced to wait an hour or more at emergency departments before they can return to duty. This is not just a waste of resources, but could represent life-threatening delays. Speed is of the essence. Special administrative arrangements should be put in place to resolve this issue and to free up ambulances as quickly as possible.

In reforming the system, the HSE decided to cut the number of ambulance control centres from 12 to two, to specify what constituted top priority call-out cases, and to provide advanced paramedic training for ambulance staff. In that process, the Health Information and Quality Authority (Hiqa) recommended that call-out times for cardiac and life-threatening cases should be, at best, less than eight minutes and, in the great majority of cases, less than 19 minutes. HSE figures show, however, that only one-quarter, and one-half of life-threatening cases, are being reached within the extended time period countrywide.

Complaints over fatal delays are most frequent in isolated, rural areas. Reform has been difficult for historical reasons and because of the fragmented nature of locally based services. Plans to centralise control and direction of all ambulances is behind schedule. Cost cutting plans involving levels of absenteeism, overtime and rostering brought trade union involvement and Labour Court arbitration. Attempts to create a fully national ambulance service and absorb the public element operated by Dublin Fire Brigade may yet cause industrial difficulties. A review of this joint ambulance/fire brigade service, which the HSE claims is too expensive and outside the remit of Hiqa, is due to be published next May.

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Whatever about a unified service and HSE control of Dublin ambulances, priority should be given to improving call-out times, particularly for country services. At this stage, turf wars represent a distraction that should be avoided. Unlike other parts of the health system, the ambulance service has been relatively well protected. The have been savings through staff reductions and work practice changes, but capital spending has grown. Modernisation, better training and additional funding are still required. The public will judge success on improved speeds in call-out response.